Claims Examiner I, Entry Level

Job Description:

Claims Examiner will be responsible for adjudicating complex claims, manually and/or automatically price claims accurately, and identify billing issues.

      Responsibilities include, but not limited to:

• Analyze, research, and process and/or adjust claims with accurate use of procedures and ICD-10 codes under respective provider and member benefits based on:

1.    Contractual agreement
2.    Health Plan division of financial responsibility
3.    Applicable regulatory legislature
4.    Claims processing guidelines

• Client group’s and company’s policies and procedures
•         Review and process facility (UB-04) and professional (CMS-1500) claims.
•         Process Medicare member claims based on DMHC and DHS regulatory legislature
•         Respond and resolve providers’ and health plans’ inquires in a timely manner
•         Review services for appropriate charges and apply authorization
•         Monitor aging claims with reports to maintain timeliness
•         Maintain quality and productivity standards
•         Participate in special projects
•         Works closely with Supervisor and reports any issues

Qualifications:

•         At least a high school diploma
•         Applicable healthcare claims adjudication experience within a managed care industry is a plus
•         Familiar with ICD-10, HCPCS, CPT coding, APC, ASC, and DRG pricing
•         Familiar with facility and professional claim billing practices
•         Must have good written and communication skills.
•         Must be able to follow guidelines, multi-task, and work comfortably within a team-oriented environment.
•         Computer literacy required, including proficient use of Microsoft Word, Excel, and Outlook. Knowledge in EZ-CAP 6X is a plus.
•         Familiar with SSRS is a plus.
•         Typing skills of at least 40 wpm.